PM Attachment 3.14.3
Behavioral Health Inpatient Facility
Admission Authorization Criteria
A. PURPOSE
Behavioral Health Inpatient Facilityi services provide treatment for children and adolescents who demonstrate
severe and persistent psychiatric disorders, when outpatient services (ambulatory care) in the community do not
meet their treatment needs and they require services at a psychiatric residential treatment facility under the
direction of a psychiatrist. These services are designed for children and adolescents who have significant deficits
in social, behavioral, psychiatric, and psychological functioning and who require active treatment in a controlled
environment with a high degree of psychiatric oversight, 24 hour nursing presence, effective program and
treatment availability, and continuous supervision provided by professional behavioral health staff.
Admissions to a Behavioral Health Inpatient Facility are not emergent or urgent and are always prior authorized.
Such admissions are only appropriate where outpatient care has failed or where the child’s/adolescent’s
psychiatric treatment needs are so severe they can only be met by the degree of specialized professional
treatment available in a Behavioral Health Inpatient Facility. Active treatment focuses on specific targeted goals
identified by the Child and Family Team, and are designed to enable the child/adolescent to be discharged from
the psychiatric residential treatment facility at the earliest possible time. A lack of available outpatient services is
not in and of itself the sole criterion for admission to a Behavioral Health Inpatient Facility.
Determination of the need for services is based on the federal regulations in 42 CFR:
§ 441.152 Certification of need for services.
(a) A team specified in § 441.154 must certify that—
(1) Ambulatory care resources available in the community do not meet the treatment needs of the recipient;
(2) Proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the
direction of a physician; and
(3) The services can reasonably be expected to improve the recipient’s condition or prevent further
regression so that the services will no longer be needed.
§ 441.154 Active treatment.
Inpatient psychiatric services must involve ‘‘active treatment’’, which means implementation of a
professionally developed and supervised individual plan of care, described in § 441.155 that is—
(a) Developed and implemented no later than 14 days after admission; and
(b) Designed to achieve the recipient’s discharge from inpatient status at the earliest possible time.
B. BEHAVIOR AND FUNCTIONING REQUIRED FOR ADMISSION
1) Symptoms or functional impairments of the individual's psychiatric condition are of a severe and persistent
nature.
2) In addition, all of the following must be met to ensure appropriate, cost-effective and least restrictive care in
this setting:
a) Ambulatory care resources (outpatient medically necessary behavioral health services) in the community
do not meet the treatment needs of the child/adolescent;
b) The child/adolescent does not require a level of medical or professional supervision that surpasses that
which is available at a Behavioral Health Inpatient Facility. For example, children/adolescents actively
showing signs of danger to self or danger to others may require inpatient psychiatric treatment at an
acute psychiatric hospital;
c) The admission is not used primarily, and in a clinically inappropriate manner, as:
i)
An alternative to incarceration, preventative detention, or as a means to ensure community safety in a
child/adolescent exhibiting primarily delinquent/antisocial behavior; or
i
* Due to recent changes in licensure Behavioral Health Inpatient Facilities now include what was formerly
referred to as Residential Treatment Center (RTC) and Level 1 Sub-acute facilities. Level II & III facilities are now
identified as Behavioral Health Residential Facilities.
3.14.1 – Page 1 of 2
Last Revised: 02/05/2014
Effective Date: 05/15/2015
PM Attachment 3.14.3
Behavioral Health Inpatient Facility
Admission Authorization Criteria
ii) The equivalent of safe housing, permanency placement, or
iii) An alternative to parents’/guardian’s or other agency’s capacity to provide for the child or adolescent;
or
iv) An intervention when other less restrictive alternatives are available and not being utilized.
C. EXPECTED IMPROVEMENT DUE TO ACTIVE TREATMENT
Active treatment with the services available at this level of care can reasonably be expected to improve the
child/adolescent’s psychiatric condition in order to achieve discharge from the psychiatric residential treatment
facility at the earliest possible time and facilitate his/her return to outpatient care and/or family living.
D. DISCHARGE PLAN
There is a written plan for discharge with specific discharge criteria and recommendations for aftercare treatment
that includes involvement of the Child and Family Team and complies with current standards for medically
necessary covered behavioral health services, cost effectiveness, and least restrictive environment and is in
conformance with 42 CFR.1 Discharge planning should start at time of admission to ensure all needs have been
addressed to prepare for a safe and supported transition to lower level services.
1
§ 441.155 Individual plan of care
(a) ‘‘Individual plan of care’’ means a written plan developed for each recipient in accordance with §§ 456.180 and
456.181 of this chapter, to improve his condition to the extent that inpatient care is no longer necessary. (b) The
plan of care must— (1) Be based on a diagnostic evaluation that includes examination of the medical,
psychological, social, behavioral and developmental aspects of the recipient’s situation and reflects the need for
inpatient psychiatric care; (2) Be developed by a team of professionals specified under § 441.156 in consultation
with the recipient; and his parents, legal guardians, or others in whose care he will be released after discharge; (3)
State treatment objectives; (4) Prescribe an integrated program of therapies, activities, and experiences designed
to meet the objectives; and (5) Include, at an appropriate time, post-discharge plans and coordination of inpatient
services with partial discharge plans and related community services to ensure continuity of care with the
recipient’s family, school, and community upon discharge. (c) The plan must be reviewed every 30 days by the
team specified in § 441.156 to— (1) Determine that services being provided are or were required on an inpatient
basis, and (2) Recommend changes in the plan as indicated by the recipient’s overall adjustment as an inpatient.
(d) The development and review of the plan of care as specified in this section satisfies the utilization control
requirements for— (1) Recertification under §§ 456.60(b), 456.160(b), and 456.360(b) of this subchapter; and (2)
Establishment and periodic review of the plan of care under §§ 456.80, 456.180, and 456.380 of this subchapter.
3.14.1 – Page 2 of 2
Last Revised: 02/05/2014
Effective Date: 05/15/2015